DEPARTMENT OF HEALTH, GOVERNMENT OF BIHAR
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eq[; eysfj;k dk;kZy;] LokLF; Hkou] lqYrkuxat] fcgkj] iVuk& 800 006nwjHkkk ,oa QSDl% 0612-2370131, bZ&esy% [email protected], [email protected]
This can be downloaded from Health Deptt. GoB web portal as- www.health.bih.nic.in in its Operational Guidelines section
for
Treatment of AES cases in Bihar
STANDARD OPERATING
PROCEDURE (SOP)
2018 (Revised)
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mipkj fd;k tk ldk ,oa ejhtksa dh la[;k ,oa e`R;q esa visf{kr deh ikbZ xbZA
foxr o"kksZa ds vuqHko ds vk/kkj ij ;g eglwl fd;k x;k fd ekud lapkyu izf;k esa dqN
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jkT; dksj dfeVh dk xBu fd;k x;k ftlesa LokLF; foHkkx ds inkf/kdkfj;ksa ds vykok vU; foHkkxksa ds
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,oa fu%'kDrrk funs'kky; ,oa thfodk ds vFkd ifjJe ls foxr o"kksZa esa efLr"d Toj ,-bZ-,l- dh
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fy, efLr"d Toj ds ihfM+rksa dk lE;d bykt lqfuf'pr djus gsrq ekxZn'kZd dk dk;Z djsxhA bl volj
ij eSa LokLF; foHkkx ds lacaf/kr inkf/kdkfj;ksa rFkk jkT; dksj dfeVh ds lHkh lnL;ksa dks c/kkbZ nsrk gw rFkk
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lans'k
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gksrh jgh gSA efLr"d Toj ls u dsoy fcgkj oju ns'k ds vU; dbZ jkT; Hkh izHkkfor gSA Hkkjr ljdkj }kjk
Group of Ministers (GoM) dh vuq'kalk ij 18 vDVwcj 2012 dks laiUu dSfcusV dh cSBd esa Multi
Pronged Strategy ds varxZr LokLF; foHkkx ds vfrfjDr vU; foHkkxksa dks Hkh blds fu;a=.k dh j.kuhfr esa
'kkfey fd;k x;k gSA blds varxZr ns'k ds ikp lokZf/kd efLr"d Toj izHkkfor jkT;ksa ,oa buds 60 fpfUgr
ftyksa esa fo'kss"k HkkSfrd ,oa fokh; xfrfof/k;ksa dk f;kUo;u fpfUgr fd;k x;k gSA blesa fcgkj ds 15 ftys]
N% fpfdRlk egkfo|ky; vLirkyksa dks Sentinal Site ds :i esa ,oa nks Physical Medicine &
Rehabilitation (PMR) dsUnzksa dks 'kkfey fd;k x;k gSA
bu 15 fpfUgr GoM ftyksa esa ICU dh LFkkiuk dh tkuh gSA N% fpfdRlk egkfo|ky; vLirkyksa ds
ekbksokW;ksykWth foHkkxksa esa fu%'kqYd JE dh tkp ds lkFk&lkFk vU; chekfj;ksa dh tkp dk izko/kku fd;k
x;k gSA jkT; dks nks PMR ;Fkk vuqxzg ukjk;.k ex/k esfMdy dkWyst ,oa vLirky (ANMMCH) x;k ,oa
iVuk esfMdy dkyst ,oa vLirky (PMCH) iVuk esa efLr"d Toj ls fnO;kax ejhtksa dks iquZokflr djus
gsrq iz;kl fd;k tk jgk gSA
efLr"d Toj ejhtksa dh fpfdRlk gsrq o"kZ 2012 esa gh Standard Operating Procedure (SOP) dk
lw=.k fd;k x;k A foxr o"kksZa ds vuqHko ds vk/kkj ij o"kZ 2018 esa bls iqu% la'kksf/kr fd;k x;k gS A eSa SOP
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foxr o"kksZa ds vuqHko ds vk/kkj ij jkT; ds 24 ftyksa esa ts-bZ- dk Vhdkdj.k y{k dk iwjk gksuk xoZ dh ckr gSA 'ks"k 14 ftyksa esa ls 11 ftyksa esa Vhdkdj.k dh lS)kafrd lgefr Hkh Hkkjr ljdkj }kjk fey pqdh gSA ckdh rhu ftyksa esa rhu o"kksZa ls fdlh Hkh ejhtksa dh igpku ugha gks ikbZ gSA
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efLr"d Toj ls xzflr fnO;kax cPpksa dks fpfr dj iquokZflr fd;k tk jgk gS rkfd oSls cPps Hkh lekt dh eq[; /kkjk esa 'kkfey gks ldsaA MsoyiesaV ikVZulZ ds lg;ksx ls jkT; ds fpfdRlk inkf/kdkfj;ksa] vk;q"k fpfdRldksa ,oa ikjk esfMdy LVkWQ dks efLr"d Toj tSlh chekjh ij fu;a=.k ds fy, izf'kf{kr fd;k tk pqdk gSA lkFk gh LokLF; foHkkx ds vU; dfeZ;ksa] vkaxuckM+h lsfodk] thfodk nhfn;ksa vkSj iapk;rh jkt izfrfuf/k;ksa ds vykos lekt ds x.kekU; O;fDr;ksa dks Hkh bl chekjh ls lacaf/kr izf'k{k.k fn;k x;k gSA
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eaxy ik.Ms;
Contents
1 Abbreviations 1-2
2 Protocol for Management of AES (Members of State Core Committee) 3
3 Acute Encephalitis Syndrome- Case Classification of AES & Definitions 4
4 Case Classification of AES 4
5 Etiology/Causes of AES 5
6 Causes of Acute Encephalitis Syndrome- 2016 6
7 Causes of Acute Encephalitis Syndrome- 2017 7
8 Management/Treatment of AES 8
9 Treatment at Community Level (ANM, ASHA & AWW) 9-18
10 Practical Aspect of Initial Management (At PHC Level) 19
11 Management of AES at PHC/Referral/Sub Divisional Hospital Level 20
12 Management of AES at District Level (Sadar Hospital) 21
13 Management of AES at Medical College 22
14 Management of Airway and Breathing 23
15 Position of the Patient 23
16 Management of Circulation 24
17 Maintenance Fluid 24
18 Management of Dehydration 25
19 Control of Convulsions & Maintenance Dose 26
20 Management of Increased Intra Cranial Pressure 27
21 Control of Temperature 28
22 Calories/Nutrition 29
23 General Management 30
24 Indications of Ventilatory Support 31
25 Treatment of Specific cause if any 32
26 Treatment of other associated complications 33-35
27 Investigations, Sample Collection & Transportation 36-37
28 Lumbar Puncture & CSF Examination 38
29 Rehabilitation 39
30 Case Investigation Form (Annexure-A) 40
31 Laboratory Request Form (Annexure-B) 41
32 Essential Equipments at the PHC/Referral/SDH/Sadar Hospital/Med.Coll. (Annexure-C) 42
33 Essential Drugs at the PHC/Referral/Sub Divisional Hospital (Annexure-D) 43
34 Essential Drugs at the Sadar Hospital/Medical College Hospital (Annexure-E) 44
35 Components of Paediatric Intensive Care Unit (PICU) (Annexure- F) 45
36 List of Equipment/Furniture required for PMR Department (Annexure-G) 46-47
37 (Annexure-H)Verbal Autopsy 48
Abbreviations
ABG Arterial Blood Gas
AES Acute Encephalitis Syndrome/Acute Encephalopathy Syndrome
ANM Auxiliary Nurse Midwifery
ASHA Acredited Social Health Activist
AVPU Alert Voice Pain Unresponsive
AWW Angan Wadi Worker
BP Blood Pressure
CCF Congustive Cardiac Failure
CNS Central Nervous System
CRT Capillary Refilling Time
CSF Cerebrospinal Fluid
CT Computed Tomography
ECG Electrocardiogram
ECHO Echocardiography
EEG Electroencephalogram
ELISA Enzyme Linked Immuno- Absorbent Assay
FRU First Referral Unit
GIH Gastro Intestinal Haemorrhage
GIT Gastro Intestinal Tract
Hb Himeoglobine
HBsAg Hepatitis B surface Antigen
ICT Intra Cranial Tension
ICU Intensive Care Unit
IgM Immunoglobulin
IM Intra Muscular
IRL Infra Red Lamp
IV Intra Venous
IVIG Intravenous Immunoglobulin
JE Japanese Encephalitis
1
Contd....
2
KFT Kidney Function Test
KGMU King George Medical University
LFT Liver Function Test
LP Lumber Puncture
MRI Magnetic Resonance Imaging
NIBP Non Invasive Blood Pressure
NS Normal Saline
ORS Oral Rehydration Solution
PaCo2 Partial Pressure of Carbondioxide
PCR Polymerase Chain Reaction
PHC Primary Health Centre
PICU Paediatric Intensive Care Unit
PMR Physical Medicine and Rehabilitation
PR Per Rectal
R/T Ryle's Tube
RBC Red Blood Corpuscle
RDT Rapid Diagnostic Test
RL Ringer Lactate
RMRI Rajendra Memorial Research Institute
RNA Ribose Nucleic Acid
RT Suction Ryle's Tube Suction
SDH Sub Divisional Hospital
SGOT Serum Glutamic Oxaloacetic Transaminase
SGPT Serum Glutamic Pyruvic Transaminase
SOS A Latin word minining- if require/if necessary
SpO Oxygen Saturation2
TBM Tuberculous Meningitis
UTI Urinary Track Infection
VEE Venezuelan Equine Encephalitis
WHO World Health Organisation
WNE West Nile Encephalitis
VA Verbal Autopsy
3
Protocol for Management of AES
Guide :-
Sanjay Kumar, I.A.S. Principal Secretary, Health Department, Government of Bihar
Members of State Core Committee on AES/JE :-
Dr. R. D. Ranjan Director in Chief, Disease control, Deptt. of Health, Bihar
Dr. M. P. Sharma Addl. Director cum State Programme Officer (VBDCP), Deptt. of Health, Bihar
Dr. Arvind Kumar Associate Professor & HoD, Deptt. of Paediatrics, SKMCH, Muzaffarpur
Dr. Bankey Bihari Singh Associate Professor & HoD, Deptt. of Paediatrics, ANMMCH, Gaya
Dr. Gopal Shankar SahniAssistant Professor, Deptt. of Paediatrics, SKMCH, Muzaffarpur
Dr. Syed Hubbe AliHealth Specialist, UNICEF Office for Bihar
Special Invitees :-
Dr. A. K. Jaiswal Professor & HoD, Deptt. of Paediatrics, PMCH, Patna
Dr. Alka Singh Associate Professor & HoD, Deptt. of Paediatrics, NMCH, Patna
Dr. Sanjay Kumar Associate Professor, Deptt. of Neurology, PMCH, Patna
Dr. Nigam P. Narain Retd. Professor & HoD, Deptt. of Paediatrics, PMCH, Patna
Dr. Braj Mohan Retd. Professor & HoD, Deptt. of Paediatrics, SKMCH, Muzaffarpur
Dr. S. M. Hassan Sr. Program Officer, PATH
Assisted by :-
Sanjay Kumar State Incharge, AES/JE Technical Cell, Chief Malaria Office, Patna
(Developed in Consultation with the following Members of State Core Committee)
4
Acute Encephalitis SyndromeDefined as a person of any age, at any time of the year with acute onset of fever and a change in mental status (including symptoms such as confusion, disorientation, coma or inability to talk) and/or new onset of seizures .(excluding simple febrile seizures)
In Bihar a few cases of such encephalopathy / AES have been observed without fever also. (Japanese encephalitis is a type of viral disease which is transmitted by bites of female mosquitoes
belonging to culex species. The disease affects the central nervous system and can cause severe complications, seizures and even death)
1. Laboratory-confirmed JE : Patient having any one of the following-
i) Presence of IgM antibodies specific to JE virus in a single sample of Cerebrospinal Fluid (CSF) or serum, as detected by an IgM-capture ELISA specifically for JE virus.
ii) Detection of a fourfold or greater rise in antibodies specific to JE virus as measured by Haemagglutination Inhibition(HI) or Plaque Reduction Neutralization Assay(PRNT) in serum collected during the acute and convalescent phase of illness. The two specimens for IgG should be collected at least 14 days apart. The IgG test should be done in parallel with other confirmatory tests to eliminate the possibility of cross-reactivity.
iii) Isolation of JE- virus in serum, plasma, blood, CSF or tissue.
iv) Detection of JE- virus antigens in tissue by Immunohistochemistry.
v) Detection of JE- virus genome in serum, plasma, blood, CSF or tissue by reverse transcriptase Polymerase Chain Reaction (PCR) or an equally sensitive and specific nucleic acid amplification test.
2. Probable JE: A Suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak.
3. Acute Encephalitis Syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified.
4. Acute Encephalitis Syndrome (due to unknown agent ): A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate.
Case Classification of AES
Definitions 1. Encephalitis: An inflammation of the brain, usually caused by a direct
invasion by micro-organism or hyper sensitivity reaction to a micro-organism or foreign protein
2. Encephalopathy: A syndrome caused by disease, damage or dysfunction of the brain and may be attributed to infectious, toxic, immune mediated or metabolic causes
5
Etiology/Causes of AESM
AIN
HE
AD
Dis
ea
se
s o
f K
no
wn
AE
S
* th 1. At AESTAG (Technical Advisory Group) meeting held at RMRI, Patna on 29 November, 2016 and chaired by Dr. Soumya Swaminathan, Secretary DHR & DG, ICMR, New Delhi in presence of Principal Secretary, Health, Govt. of Bihar, Dr. S. Venkatesh, Director NCDC, GoI, Delhi, Dr. P. K. Sen, Additional Director, NVBDCP, GoI, Delhi and others, the decision taken was as The cases diagnosed as Dengue, Malaria, Scrub Typhus and T.B. should be removed from the AES pool to avoid unnecessary inflation in AES figure.
2. As per above decision causes of Dengue, Malaria, Scrub Typhus & T.B. are to be reported concerned division only and not as AES cases.
Viral Encephalitis (Except JE)
Entero-Viral Encephalitis
Non-Polio
Single Stranded RNA Virus of Flaviviridae family (Mosquito is vector)
Polio
Coxsackie A&B
Echo Virus
Others
Measles
Mumps
Dengue
Herpes Encephalitis
Nipah Encephalitis
Chandipura Virus
Varicella (Chicken Pox)
Unknown (eg- Aseptic Meningitis, Acute Disseminated Encephalomylitis (ADEM).
*
Non Viral Encephalitis
Arbovirus WNE (Arthopod is vector) (West Nile Encephalitis in North America)
VEE (Venezuelan Equine Encephalitis)
Tick Borne Encephalitis & others
Dawson Encephalitis
I) Infections :-
Bacterial (Pyogenic Meningitis) * TBM (Tubercular Meningitis) * * Parasitic (Malaria , Round Worm, NCC)
Toxoplasmosis Leptospirosis
* Rickettsial Infection (Scrub Typhus) Protozoal (Amoebic) Spirochetal (Syphilis) Fungal (Cryptococal)
Trypanosomiasis
II) Hyper Pyrexia (Heat Stroke)
III) Hypoglycemia
IV) Chemicals (No fever)
V) Toxins (Toxins of some fruits and insecticides)
VI) Dyselectrolytemia
Usually not
Found inIndia
UnknownAES
JapaneseEncephalitis
KnownAES
AES
6
Unknown AES
JE (+ve)
Known AES
AES Classification Cases AES Classification (%)
Unknown AES 224 52.8%
JE (+ve) 100 23.6%
Known AES 100 23.6%
Total 424 100%
Etiology of AES Cases 2016 Cases Etiology of AES Cases (%)
Pyogenic Meningitis 67 67.0%
Herpes Encephalitis 10 10.0%
Measles Encephalitis 5 5.0%
Chandipura Virus 4 4.0%
Chicken Pox Encephalitis 4 4.0%
Post Measles Encephalitis 4 4.0%
ADEM 2 2.0%
Aseptic Meningitis 2 2.0%
Dyselectrolytemia 1 1.0%
Mumps Encephalitis 1 1.0%
Total 100 100.0%
Pyogenic Meningitis
Herpes Encephalitis
Measles Encephalitis
Chandipura Virus
Chicken Pox Encephalitis
Post Measles Encephalitis
ADEM
Aseptic Meningitis
Dyselectrolytemia
Mumps Encephalitis
Etiology of Known AES Cases- 2016, Bihar
AES Classification- 2016, Bihar
Based on AES Cases of Bihar in Year 2016
Causes of Acute Encephalitis Syndrome
(n=424)
52.8%
23.6%
23.6%
(Unknown AES)
[JE (+ve)]
(Known AES)
(n=100)
67.0%
10.0%
5.0%
4.0%
4.0%
4.0%
2.0%
2.0% 1.0% 1.0%
7
Etiology of AES Cases Cases Etiology of AES Cases (%)
Herpes Encephalitis 19 49%
Hypoglycemia 9 23%
Dyselectrolytemia 5 13%
Pyogenic Meningitis 4 10%
NCC 1 3%
West Nile Encephalitis 1 3%
Total 39 100.0%
Etiology of Known AES Cases- 2017, Bihar
AES Classification- 2017, Bihar
Based on AES Cases of Bihar in Year 2017
Causes of Acute Encephalitis Syndrome
Unknown AES
JE (+ve)
Known AES
50%32%
17%
(n=228)
Herpes Encephalitis
Hypoglycemia
Dyselectrolytemia
Pyogenic Meningitis
NCC
West Nile Encephalitis
49%
23%
13%
10%
3%3%
(n=39)
AES Cases AES
Classification Classification (%)
Unknown AES 115 50%
JE (+ve) 74 32%
Known AES 39 17%
Total 228 100%
(Unknown AES)
(Known AES)
[JE (+ve)]
8
A. History and Clinical examination
1. Detailed clinical examination of the patient including status of hydration and level of consciousness
2. History of previous similar illness in the patient/ neighboring community
3. History of preceding day / nights diet including consumption of any fruits and vegetables
B. Site of Management/Treatment of AES
1. At Community level
2. Practical aspect of initial Management at PHC
3. At PHC/Referral/Sub. Divisional Level
4. At District Level
5. At Medical College Level
C. Details of Systematic Management of AES at Facility Level-
1. Management of airways and breathing
2. Management of circulation
3. Management of dehydration
4. Control of convulsions
5. Management of increased intracranial pressure
6. Control of Temperature
7. Calories & Nutrition
8. General management
9. Indications of ventilatory support
10. Treatment of specific cause if any
11. Treatment of other associated complications
12. Investigations, sample collection & transportation
13. Lumbar puncture & CSF examination
14. Rehabilitation
15. Reporting of a case
ANM/ASHA/AWW Medical Officer & Specialist
Management/Treatment of AES
}
9
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5- cPps ds 'kjhj ls diM+s gVk ysa ,oa Nk;knkj txg esa mls fyVk;sa ,oa xnZu lh/kk j[ksaA
6- ;fn ejht ds eqg ls >kx ;k ykj ckj&ckj o T;knk fudy jgk gS rks lkQ iV~Vh ;k diM+s ls ejht dk eqg lkQ djrs jgsaA
7- ejht dks ;fn >Vds vk jgs gksa rks mlds nkarks ds chp lkQ diM+ksa dk ,d xksyk cukdj j[ksa] ftlls thHk dVus ls cp ldsA
* cPps ds csgks'k gksus dh fLFkfr esa bls vkek'k; esa uyh Mky dj fn;k tk ldrk gSA
xko Lrj ij ,-,u-,e-] vk'kk] vkxuckM+h lsfodk ,oa Lo;a lgk;rk lewg (SHG) }kjk efLr"d Toj rFkk
bl rjg ds y{k.k lewg ds ejhtksa dk mipkj
Contd....
10
pedh vkus dh fLFkfr esa %
C ejht dks djoV ;k isV ds cy fyVk;saA
C 'kjhj ds diM+s
11
ejht dks utnhdh izkFkfed LokLF; dsUnz esa Hkstus ds e esa fuEu lko/kkuh cjrsa %
C ;fn cq[kkj rst gks rks ikuh ls cnu iksNasA
C ;fn IV ykbu yx lds rks IV Fluid yxk dj HkstsaA
C mYVh gksus dh n'kk esa IV Fluid ukeZy lsykbu ek=k 1 fdyksxzke otu ds fy;s 20 feyh ,d ?k.Vs esa yxk;sa mlds ckn IV Fluid ukeZy lsykbu yxk dj Hkstsa ek=k 15 fdykxzke otu ds fy;s 10&12 cwn izfr feuV
C pedh vkus dh n'kk esa] ejht dks ck,W ;k nk, djoV esa fyVkdj ys tk,aA
C vius MkWDVj ;k izk Lok dsUnz ds MkDVj ls lEidZ dj vko';d funsZ'k izkIr djsaA
C csgks'k @fof{kIr@>Vds dh voLFkk esa cPps ds eqg esa nok] ikuh] twl] nw/k ;k Hkkstu ugha MkysaA
vfoyac cPps dks utnhd ds izkFkfed Lok dsUnz@jsQjy vLirky@vuqeaMyh; vLirky@lnj vLirky@esfMdy dkWyst ds f'k'kq jksx foHkkx esa bZykt gsrq ykosaA blds fy, 102@108 ,Ecqysal *lsok dk mi;ksx djsaA
efLr"d Toj ds ejhtksa dh igpku gksus ij D;k ugha djuk pkfg, %
C cPps dks dEcy ;k xeZ diM+ksa esa u yisVsaA
C cPps dh ukd can u djsaA
C csgks'kh@fexhZ dh voLFkk esa cPps ds eqg esas dqN Hkh u nsaA
C cPps dh xnZu >qdh u jgsA
C pwafd ;g nSfod izdksi ugh gS cfYd vR;f/kd xehZ ,oa ueh ds dkj.k gksus okyh chekjh gS vr% cPps ds bZykt esa vks>k xq.kh esa le; u"V u djsaA
,Ecqysal pkyd dks bl ckr dk /;ku j[kuk pkfg, fd ,0bZ0,l0 ejht dks ykus ds nkSjku
fdlh izdkj dk 'kksj tSls lk;ju] gkuZ] vf/kd rst eksckbZy fjax Vksu] jsfM;ks bR;kfn dk iz;ksx u gksA
Contd....
LokLF; laca/kh rRdky bejtsUlh lsok] vkdfLed ,oa
vfregRoiw.kZ f'kdk;r gsrq VkWy h uacj Mk;y
djus ds ckjs esa turk dks voxr djk,A104
108 102/108*
* dsoy iVuk 'kgjh {ks= esa ,Ecqysal dh VkWy h lsok gsrq 108 uEcj ij MkW;y djsaA
12
efLr"d Toj ls cpko gsrq mik; ,oa lko/kkfu;k %
C vius cPps dks ts-bZ- dk Vhdk vo'; yxok;saA
C [kku&s ihu s e as mcy s g,q ikuh dk mi;kxs lfq uf'pr dj as vFkok
ihu s d s ikuh d s fy, bafM;k ekdZ& II/III gSaM iEi dk i;z kxs
djAas vko';drk iMu+ s ij Dykjs hu dh xkfs y;k a vFkok
Cyhfpxa ikmMj dk i;z kxs djAas
C uy ds pkjksa vksj dahV dk pcqrjk ,oa de&ls&de 10
ehVj nwj ikuh dk fudkl lqfuf'pr djus ds fy,
fudkl ukyh dk fuekZ.k djk;saA
C 40 QhV ls de xgjkbZ ds gSaM iEiksa dk ikuh u fi;saA
C rkykc ;k iks[kjs ds ikuh dks ugkus ;k eqg /kksus ds fy,
Hkh iz;ksx u djsaA
C gSaM iEi ds pkjksa rjQ ikuh bdV~Bk u gksus nsa rFkk ty
L=ksr ds pkjksa rjQ iznw"k.k QSykus okyh xfrfof/k;k tSls%
ey&ew=] ty teko] diM+s ;k crZu /kksuk] tkuojksa dks
/kksuk bR;kfn u djsaA
C yky jax ls jaxs gq, pkikdy dk ikuh ihus /;ku j[ksa&
;ksX; ugha gSA
C ;fn ihus dk ikuh bDV~Bk dj ds j[krs gS rks mlesa dHkh
Hkh gkFk u Mkysa] cfYd mls fudkyus ds fy, LoPN
gS.My yxs ex dk iz;ksx djsaA
C ekulwu ds iwoZ ,oa ekulwu ds i'pkr~ PHED dss pkikdy
ds ikuh dh xq.kokk dh fu%'kqYd tkp ftyk ty tkp
iz;ksx'kkyk* ls vo'; djok;saA
C tkuojksa dks vius jgus dh txg ls FkksM+k nwj ,oa
lkQ&lqFkjk j[ksaA
C 'kkjhfjd LoPNrk dk iwjk /;ku j[ksa ,oa ey foltZu
leqfpr ,oa lqjf{kr 'kkSpky;ksa esa gh djsaA
C [kkus ls iwoZ ,oa 'kkSp ds ckn lkcqu ls gkFk vo'; /kks,A
C fcLrj ij ePNjnkuh dk iz;ksx djuk pkfg,A
C ifjokj d s jgu s oky s dejk as e as ePNj Hkxku s okyh vxjcRrh ;k nlw jh nokb;k as dk mi;kxs djuk pkfg,A
Contd....
bafM;k ekdZ& II/III gSaM iEi
13
Contd....
C iwjs 'kjhj dks kfM+;ksa dh lkQ&lQkbZ djrs jguk pkfg,A
C tyh; i{kh tSls & lkjl] cxqyk] ck[k bR;kfn ds ek/;e ls Hkh efLr"d Toj QSyrk gSA vr% o"kkZ ds
fnuksa esa /kku ds [ksrksa esa tes gq, ikuh esa] iks[kj@rkykcksa ds utnhd vius cPpksa dks ugha Hkstuk
pkfg,A
C cxhps esa fxjs gq, twBs Qyksa dks cPpksa dks ugha [kkus nsuk pkfg,A
C xehZ ds fnuksa esa cPpksa dks ORS dk ?kksy fiykuk pkfg, ;fn ORS dk ?kksy ugha feys rks uhcw ikuh
vo'; fiykuk pfkg,A
C rst jkS'kuh ls cpkus ds fy, ejht dh vkW[kksa dks iV~Vh ;k diM+s ls kx fudy jgk gks rks lkQ diM+s ls iksNas] ftlls fd lkal ysus esa dksbZ fnDdr
uk gksA
vks-vkj-,l- ?kksy cukus dh fof/k %
C lkQ crZu esa ,d yhVj ikuh lk/kkj.k Xykl ls ikp fxykl esa vks-vkj-,l- dk ,d iwjk iSdsV ?kksy nsaA
C vxj cPpk gks'k esa gks rks rS;kj fd;s x, vks-vkj-,l ds ?kksy dks dqN&dqN varjky ij pEep ls nsrs jgsa rFkk cuk;s x;s ?kksy dks 24 ?kaVs ds ckn mi;ksx u djsaA
C vks-vkj-,l- dk iSdsV fudVre ljdkjh vLirky@LokLF; midsUnz@vk'kk ds ikl miyC/k gSA
C lwvjksa dk ePNjksa ls cpko o lwvjckM+ksa esa lq/kkj %
iDds lwvjckM+ksa ls cpko dk fuekZ.k] f[kM+dh ,oa njokts ij ePNj tkyh dh O;oLFkk rFkk ikuh ,oa lQkbZ dh leqfpr O;oLFkkA
lwvjckM+ksa esa VsfDudy eykfFk;kWu QkWfxax dh O;oLFkkA
lwvjksa ds ey&ew=ksa ds fy, lw[ks o
14
lwvjksa ds gj txg fopj.k dks jksdus ds fy, f'k{kk ,oa fn'kk funsZ'kA
lwvj dkVus ds LFkku dk fu/kkZj.k ,oa lQkbZA
lqjf{kr lwvjckM+ksa dk fuekZ.k cfLr;ksa ls nwj gksuk pkfg,A
lwvj ikydks dks ;g tkudkjh nsus dh vko';drk gS fd vxj lwvj ds cPpkssa esa vpkud chekjh gks ;k e`R;q gks ;k e`r xHkZikr gks rks os bldh lwpuk vius xko ds eqf[k;k dks nsaA
oSKkfudksa dk ekuuk gS fd flQZ lwvjckM+ksa dks ePNjjks/kh lwvjckM+k cukus ls ykHk ugha gksxk vxj lwvjksa ds ?kweus ij vadq'k ugha yxsA
C tkikuh balsQykbfVl ds ejht izfrosfnr gksus ij dsoy izHkkfor xkoksa esa VsfDudy ekWykfFk;kWu ds QkWfxax djkus gsrq izHkkjh fpfdRlk inkf/kdkjh ls laiZd LFkkfir djuk pkfg,A
C fofnr gks tkikuh balsQykbfVl fu;a=.kkFkZ VsfDudy ekWykfFk;kWu dk QkWfxax lw;kZLr ds mijkar fd;k tkrk gS] tcfd Msaxw fu;a=.kkFkZ QkWfxax lw;ksZn; ds i'pkr ,oa lw;kZLr ls igys fd;k tkrk gSA ;g vR;ar egRoiw.kZ gSA
C efLr"d Toj ds ejht bZykt ds ckn ;fn viax ik, tk,sa rks vfoyEc bldh lwpuk izHkkjh fpfdRlk inkf/kdkjh dks nh tk,A
C chekjh dk 'kq: esa irk py tkus ls vkSj mipkj tYnh 'kq: gks tkus ls jksxh dh tku cpkbZ tk ldrh gSA
C ,-,u+-,e- vk'kk ,oa vkaxuokM+h lsfodkvksa dks pkfg, fd bl chekjh ds ckjs esa vke turk dks tkx:d djsaA
C fo'ks"k ifjfLFkfr esa fu%'kqYd fpfdRlk gsrq izkFkfed LokLF; dsUnz esa cPpksa dks Hkstuk pkfg,A
izksRlkgu jkf'k dk izko/kku &
tSiuht balsQykbfVl vFkok efLr"d Toj AES-Unknown Cause) ds ejhtksa dk fpfdRlk inkf/kdkjh }kjk lR;kiu fd, tkus ds i'pkr gh vk'kk dk;ZdrkZ dks : 300@& rhu lkS :i;s ek= izR;sd ejht dh nj ls izksRlkgu jkf'k fn, tkus dk izko/kku gSA fo'ks"k tkudkjh gsrq vius izkFkfed LokLF; dsUnz ds izHkkjh fpfdRlk inkf/kdkjh vFkok ftys ds osDVj tfur jksx fu;a=.k inkf/kdkjh ls laidZ fd;k tk ldrk gSA
15
C fcgkj ds yhph iSnkokj okys ftyksa esa izfrosfnr efLr"d Toj vU; ftyksa ls vyx D;ksa gS \
fcgkj ds yhph iSnkokj okys ftyksa esa efLr"d Toj Acute Encephalopathy dh rjg yf{kr gksrk
gSA
bl chekjh es ejhtksa ds efLr"d esa lwtu gks tkrk gSA ;g mu txgksa ij ik;k tkrk gS tgk yhph
ds cxku ik, tkrs gSaA
lkekU; efLr"d Toj ds ejhtksa esa tks y{k.k ik;s tkrs gS yxHkx ogh y{k.k yhph iSnkokj okys
ftyksa ds izfrosfnr ejhtksa esa Hkh ik;s x, gSaA
ysfdu yhph iSnkokj okys ftyksa esa bl rjg ds ejhtksa esa mi;qZDr y{k.k lqcg 3 cts ls fn[kus
yxrs gSaA bu ejhtksa ds [kwu esa phuh dh ek=k ,dk,d de gks tkrh gS ,oa ejht dkQh xaHkhj gks
tkrs gSaA
dqN ejhtksa es ;g Hkh ik;k x;k gS fd mUgsa cq[kkj ugha Fkk] lksus ls igys cPps ,d ne LoLF; utj
vk jgs Fks vkSj lqcg esa mudh rfc;r vpkud [kjkc ikbZ xbZA
bl chekjh ls izHkkfor ejht dk le; ij bZykt ugha gksus ij tku Hkh tk ldrh gSA
C bl chekjh esa yhph dh D;k Hkwfedk gS\
'kks/k esa ik;k x;k gS fd yhph ds cht] v/kids ,oa ids yhph ds Qy esa ,d ,slk gkfudkjd
jlk;u gS tks [kwu esa phuh ds Lrj dks ,dk,d de dj nsrk gS ,oa ejht xaHkhj voLFkk esa pyk
tkrk gSA bl rjg dk gkfudkjd jlk;u iwjs ids gq, yhph ds Qy esa de ek=k esa ik;k x;k gSA
ejhtksa esa mi;ZqDr y{k.k yhph ds Qy esa ik;s x, gkfudkjd jlk;u ds dkj.k gksrk gSA
C ;g chekjh dc gksrh gS \
veweu bl chekjh ds ejht yhph ds ekSle vFkkZr~ vizSy ekg ds var ls twu ekg ds var rd ik,
tkrs gSaA cjlkr ds lkFk bl chekjh ds y{k.k yxHkx lekIr gks tkrs gSaA
C ;g chekjh fdl dks gks ldrh gS \
1 ls 15 o"kZ ds dqiksf"kr cPpksa dksA
oSls ifjokj tks yhph ds cxkuksa ds vkl&ikl jgrs gksa ,oa yhph dk lsou izk;% djrs gksaA
oSls dqiksf"kr cPps tks v/kids vFkok ids gq, yhph dk lsou djrs gksaA
yhph iSnkokj okys ftyksa ds fy, efLr"d Toj dh jksdFkke ,oa izca/ku gsrq ekxZnf'kZdk
Contd....
16
oSls dqiksf"kr cPps tks isV Hkjus ds fy, dsoy yhph dk gh lsou djrs gksaA
oSls cPps tks yhph [kkus ds ckn fcuk HkjisV Hkkstu fd;s jkr esas lks tkrs gksaA
oSls cPps tks xehZ ds fnuksa esa fcuk [kkuk ikuh dh ijokg fd;s /kwi esa [ksyrs gksaA
mi;ZqDr cPpksa esa bl chekjh ds gksus dh laHkkouk T;knk gksrh gSA
C bu ejhstksa dk mipkj fdl rjg ls fd;k tkuk pkfg,\
lkekU; efLr"d Toj ds ejhtksa dh Hkkafr gh bu ejhtksa dk mipkj fd;k tkuk pkfg,A
C bl chekjh dh jksd&Fkke esa vk'kk] vkaxuckM+h lsfodk ,oa ANM dh D;k Hkwfedk gS\
ekxZnf'kZdk esa ftl rjg efLr"d Toj ds ejhtksa ds lkFk D;k djuk pkfg, ,oa D;k ugha djuk
pkfg, dk mYys[k gS Bhd oSls dh AES ds ejhtks ds lkFk djuk pkfg,A
loZizFke ejht dks ;fn csgks'k u gks rks mls ORS vFkok phuh ;k Xywdkst dk ikuh fiyk;saA
;fn vk'kk vFkok ANM ds ikl XywdksehVj gks rc ejht ds [kwu esa phuh dh ek=k dh tkp vo';
djk;saA
ikjklhVkeksy dh nok mez ds fglkc ls f[kyk,A
Ambulance gsrq VkWy h la[;k 102@108 uEcj ij Qksu djsaA*
fudVre PHC, Referral vFkok ftyk vLirky dks ejht ds vkus dh iwoZ lwpuk nsaA
leqnk; esa chekjh dh igpku ,oa jksd&Fkke gsrq leqnk; esa tkx:drk QSyk,A
ejht dks fp= esa fn[kk;s x;s voLFkk esa fuEufyf[kr lko/kkfu;ksa ds lkFk fyVk dj utnhdh
LokLF; dsUnz esa Hkstsa&
lkal dh uyh [kqyk j[kus ds fy, jksxh dks ,d rjQ fyVk,WA
Bqh dks mBk dj j[ks vkSj ,d gkFk xky ds uhps j[k nsaA
'kjhj dh fLFkfr dks fLFkj j[kus ds fy, ,d iSj eksM+ nsaA
Contd....* dsoy iVuk 'kgjh {ks= esa ,Ecqysal dh VkWy h lsok gsrq 108 uEcj ij MkW;y djsaA
17
C bl chekjh ls cpko ds fy, D;k lko/kkfu;k cjruh pkfg,\
xehZ ds ekSle esa cPpksa dks HkjisV [kkuk ,oa ikuh vFkok ORS ;k Xywdkst ;k phuh dk ?kksy
fiykdj gh ?kj ls ckgj fudyus nsaA
vizSy ds vafre lIrkg ls twu ds vafre lIrkg rd vk'kk] vkaxuckM+h ,oa ANM }kjk mu ifjokjksa
ds ?kjksa dk vo'; Hkze.k fd;k tk, tgk 15 lky ls de mez ds cPps vius ifjokj ds lkFk yhph
ds ckxkuksa ds vkl&ikl jgrs gksaA
,sls lHkh ifjokjksa dks yhph ls gksus okys uqdlku ds ckjs esa ckj&ckj voxr djk;k tk,A
v/kids vFkok dPps yhph ds lsou ls cpk tk,A
ekrk&firk dks ;g vo'; lykg nh
tk, dh cPpksa dks jkr esa lksus ls
igys HkjisV [kkuk f[kyk;k tk,A
vkyw] 'kdjdan] Tokj cktjs dh
jksfV;ksa esa dkckZsagkbZMsM rRo T;knk
gksrs gSa tks jDr essa 'kqxj dh ek=k dks
de ugha gksus nsrs gSaA vr% [kkus esa
bldks t:j 'kkfey fd;k tk;sA
vxj cPps us fnu esa yhph dk lsou
fd;k gks rks mls vk/kh jkr esa Hkh
mBkdj [kkuk vo'; f[kyk;k tk;s
ftlls cPps ds [kwu esa 'kqxj dk
lgh Lrj cuk jgsA
yhph dk lsou oftZr ugha gSA mi;qZDr lko/kkfu;ksa ds lkFk yhph dk lsou fd;k
tk ldrk gSA
vxj cPpksa dks pedh vk jgh gks rks eqg esa dqN u MkysaA ;fn cPpk dqN ihus dh fLFkfr esa gks rHkh
mls ORS vFkok phuh ;k Xywdkst dk ikuh fiyk;saA
;g vko';d gS fd vk'kk] vkaxuckM+h lsfodk ,oa ANM ds ikl utnhd ds PHC, Referral
Hospital ,oa Ambulance dk eksckbZy u gks ftls t:jr iM+us ij bLrseky fd;k tk ldsA
bl chekjh ds dkj.kksa] y{k.kksa] D;k djuk pkfg, (Do's) rFkk D;k ugha djuk pkfg, (Don'ts) ds
laca/k esa leqnk; dks tkx:d djuk pkfg,A
18
lkcqu ls gkFk /kksus dk lgh rjhdk
gkFkksa dks lkcqu ls vPNh rjg /kksus ls ge cgqr lh chekfj;ksa ls cp ldrs gSaA
19
Practical Aspect of
Initial Management (at PHC level)
AES patient
Put I.V Line
Proper positioning of patient and suction
Give Diazepam @0.3mg/kg and @not more than 1mg/min (if convulsion)
Start Ringer Lactate @70-100ml/kg (according to degree of dehydration)
Apply Glucometer
Hypoglycemia
Give 5ml/kg of 10% Dextrose IV bolus.
Monitor for danger signs and plan for referral
ALERT- Never start with dextrose infusion, follow the above protocol and
Treat fever as per protocol
20
Fever
Tap water sponging
Paracetamol
Convulsions
Anti convulsants
Secretion
Suction
Nil orally
Position of patient prone/semiprone with head on one side
Oxygen if required
I/V line -I/V fluids
Correction of blood sugar - 5ml/kg of 10% Dextrose
I/V anti convulsant if convulsions are not controlled
Use of Ambu bag to assist respiration if necessary
Catheterization if required
Use of Inj. Mannitol 20%
Fluid intake/output chart
Pulse, respiratory rate, temperature and B.P. monitoring 4 hourly.
DANGER SIGNS
Needing referral to Sadar Hospital
Fever with any one of the following :
Lethargy
Unconsciousness
Convulsions
Other findings eg. paralysis, rash
Hepato-splenomegaly
For Laboratory investigation according to the type of facilities refer to page no. 36
At PHC/Referral/Sub Divisional Hospital
Management of AES
21
Fever
Tap water sponging
Paracetamol
Convulsions
Anti convulsants
Secretion
Suction
Nil orally
Position of patient prone/semiprone with head on one side
Oxygen if required
I/V line-I/V fluids
Correction of blood sugar - 5ml/kg of 10% Dextrose
I/V anti convulsant if convulsions are not controlled
Use of Ambu bag or ventilatory respiratory assistance if required
Catheterization if required
Use of Inj. Mannitol 20%
Fluid intake/output chart
Pulse, Respiratory rate, temperature and B.P. monitoring every 4 hourly
Management of unconscious patients
Management of other related ailments
DANGER SIGNS
Needing referral to nearest Medical College Hospital
Shock/low BP/rapid & thready pulse
Need of ventilator-poor respiratory efforts, cyanosis not managed by oxygen
At District Level (Sadar Hospital)
Management of AES
22
Fever
Tap water sponging
Paracetamol
Convulsions
Anti convulsants
Secretion
Suction
Nil orally
Position of patient prone/semiprone with head on one side
Oxygen if required
I/V line-I/V fluids
Correction of blood sugar - 5ml/kg of 10% Dextrose
I/V anti convulsant if convulsions are not controlled
Use of Ambu bag or ventilatory respiratory assistance if required
Catheterization if required
Use of Inj. Mannitol 20%
Fluid intake/output chart
Pulse, respiratory rate, temperature and B.P. monitoring every 4 hourly
Management of unconscious Patients
Management of shock and other complications if any
Management of AESAt Medical College
23
Management of Airway and Breathing
Assessment of Airway and Breathing
Clear Airways
No oral feed
Nurse in semi prone and prone position
Give oxygen if needed
Obstructed breathing/ severe respiratory distress
Clear Secretions from mouth
Wiping oral cavity
Suction of mouth turning head on one side
Give oxygen
Ventilate with Bag and Mask/Endo Tracheal Tube if breathing is labored.
Refer the case to tertiary care centre for ventilatory support if needed
Position of the Patient
Turn the Patient on the Prone or Semiprone side to reduce
risk of aspiration
Keep the neck slightly extended and stabilize by placing
one hand below cheek
Bend one leg to stabilize the body position.
24
Management of Circulation
Establish IV line. Look for signs and symptoms of shock Capillary refill > 3 secs Cold extremities Weak and rapid pulse
Assess pediatric patient for dehydration
No dehydration Symptomatic Management Look for signs of referral 2/3rd of maintenance fluid by
intravenous route.
Grade dehydration as some/severe dehydration
Severe dehydration. IV fluid Ringer lactate/ Normal Saline as per WHO guideline.
S o m e d e h y d r a t i o n I V f l u i d - R i n g e r Lactate/Normal Saline.
Shock present-IV fluid NS/ Ringer Lactate 20ml/kg in first hr
(Repeat 3 times if shock persists)
Reassess
NS/Ringer Lactate-20ml/kg. if shock improves and child is euvolemic, give maintenance fluid.if shock persists- Inotrope Dopamine drip in maintenance fluid 5 mcg/kg/minute then again increase Dopamine upto 20 mcg/kg/minute and similarly.Dobutamine start with 5 mcg/kg/minute & increase upto 20 mcg/kg/minute (till BP stabilizes)
Improvement : Continue maintenance IV fluid.No improvement : Refer to higher centre
NB : 1. These are broad guidelines; ultimate decision regarding management will depend upon the attending physician.
2. Management of Circulation - 3% NS 3 -5ml / kg over 1-2 hours if hyponatremia is symptomatic and documented.
Maintenance fluidMaintenance fluid administered at the following rate :
Weight (kg)
1-10
11-20
21-40
Fluid Volume/Day
100 ml/kg
1000 ml + 50ml/kg over & above 10kg
1500 ml + 20 ml/kg over & above 20 kg
(Fluid and Electrolyte Management)
25
Some Dehydration :
IV fluid Ringer lactate/normal saline 75ml/kg to be given over 4 hrs.
Where the facility for IV fluids is not available administer ORS 75 ml/kg 4 hrs through nasogastric tube.
Reassess :
If there is improvement continue with maintenance IV fluid/if no improvement is detected, switch to treatment for severe dehydration.
Severe Dehydration :
IV fluid Ringer lactate 100ml/kg is given as per the table below :
Rate of Fluid (Ringer Lactate)
< 1yr
> 1yr
30ml/kg
1hrs
1/2 hrs
70ml/kg
5hrs
2 hrs
Reassess :
If there is improvement switch to maintenance/ if no Improvement is detected or deterioration is observed infuse IV fluid more rapidly.
Management of Dehydration
26
Control of Convulsions For Convulsing Child :
Good for control & as maintenance
Sl. NoName of
Drugs Doses Available asRoute of
AdministrationIndication
Limitation/side effects
1
2
4
3
5
6
Diazepam
Lorazepam
Midazolam
Phenytoin Sodium
Phenobarbitone
Sod. Valporate
0.1-0.3mg/kg (0.5mg/kg for rectal use)
0.05-0.1 mg/kg
0.2 mg/kg
15-20 mg/kg
20mg/kg as loading dose (upto total 40mg/kg in increment of 10mg/kg)
20-40mg/kg
10mg/2ml rectal-2.5mg/2.5ml
2mg/ml
1mg/ml in 5ml & 10 ml vials Intra nasal spray
100mg/2ml amp.
200mg/ml ampule
100mg/1ml 400mg/4ml 1000mg/10ml Amp.
I/V Slowly/Suppository/(P/R)
I/V Slowly
IV, Intra Nasal, Sublingual
I/V Slowly after dilution in normal saline
I/V slowly after dilution in normal saline
IV
Uncontrolled convulsions
Uncontrolled convulsion
(Safe in infants)
Uncontrolled convulsion
Convulsion in all age groups
Convulsion in infants can be used in all age groups
All age group
May cause respiratory arrest in newborns & infants. short acting
Tachycardia, Depression, Confusion, Blurred vision
Short acting
Good drug for control of seizure & as maintenance
Good drug controlling seizure & long term use.
Note: After the control of convulsions by either Diazepam or Lorazepam or Midazolam, loading dose of Phenytoin should be given to prevent recurrence of seizures in the next 24 to 48 hours till the maintenance dose of drugs are given.
Maintenance Dose :
Phenobarbitone 3-5 mg/kg/day (Q-12 Hrs.) I/V or oral
Phenytion 5-8 mg/kg/day (Q-12 to 24 Hrs.) I/V or oral
Sodium valproate 20-60 mg/kg/day (Q-8 to 12 Hrs.) Oral
Total duration of anti convulsants to be decided by individual causes.
27
C Mannitol 20% I/V - 5ml/kg in 30 minutes as first dose then 2 ml/kg at 8 hrs. interval upto 48 hours (maximum 8 doses)
C+ 3% NS- 3-5ml/kg over 1-2 hrs. if hyponatremia co-exists (Target serum Na
around 150-155)
C Injection Lasix I/V - 1mg/kg upto 40 mg can be given
C Glycerol solution : Oral - 0.5 ml/kg mixed with fruit juice can be given by nasogastric tube (3 times a day)
C Steroids are not indicated in Viral Encephalitis including JE
C Mechanical Ventilation- Target PaCO 30mmHg2
C Head should be kept in neutral position with elevation of the head end of the bed upto 30 degree
*Recognised clinically by :
Abnormal tonic posturing
Pupillary dilatation specially if unilateral or non reacting
Periodic or Irregular respirations or Hyperventilation.
Bradycardia /Hypertensionth
Squint due to 6 nerve Palsy.
Management of Increased Intracranial Pressure*(Only after correction of Dehydration & Stabilization of Blood pressure)
28
Control of TemperatureC If No Rigors :
Tap Water Sponging : Not only on forehead, palms or soles but whole body to be wet with tap water and fan (ceiling/table/manual) should be on (Cold sponging is harmful).
Oral Paracetamol : 15mg/kg maximum upto 600mg (or by Nasogastric tube).
Injection Paracetamol : 5mg/kg by IV drip (infusion) SOS or deep intra muscular at either lateral side of thigh or upper outer Quadrant of hip.
If Injection is not available give paracetamol Suppository.
Other antipyretic medicines e.g.- Nimesulide/Brufen/Meftal/Aspirin etc are not advisable, specially in children.
C If Chills or Rigors present:
Don't cover patients
Don't do water sponging
Use Paracetamol I.M injection or syrup through nasogastric tube or parecetamol suppository as per advise.
Only for Heat Stroke, Paracetamol may not be effective therefore cold 0sponging should be continued till temperature is brought down (100 - 102 F).
29
During CNS infections with convulsion and hyperpyrexia state, calories specially
glucose requirement is increased and it should be given in form of 10% Dextrose which
may be given to the patient in a bolus dose of 5ml/kg body weight followed by a series
of maintenance doses after stabilization. All IV fluids with Dextrose should be
continued till patient is stabilized, convulsions are controlled and there is no vomiting
and distension of abdomen. At this time, intra gastric feeding may be added and slowly
IV fluids are replaced by total nasogastric feeding.
Calories/Nutrition
30
Suction :
Frequent suction (side effect- ICT) either by mucus sucker or suction machine is to be done on an unconscious patient, so that secretion may not collect in mouth to avoid aspiration and for the maintenance of the patency of airways. Avoid touching posterior part of throat (Pharynx), it may increase ICT or cause bardycardia.
Nasogastric Aspiration :
Nil orally, place a nasogastric / Ryles' Tube into stomach and do a frequent suction to avoid any vomiting and aspiration. It will also help in decompression of stomach and will decrease intra abdominal pressure. Thus, it will help in respiration.
Care of Eye, Bowel, Bladder & Back :
C Eyes to be covered by wet gauge
C An antibiotic eye ointment may be applied twice a day or liquid paraffin may be put in eyes to avoid drying of Cornea
C If child does not pass stool, put a glycerine enema
C Bed should be well maintained, to prevent formation of bed sore. Spirit & powder may be applied on back and on all pressure points
C Frequent changing of patient's position
C Catheterize the patient to avoid soiling of beds
C Physiotherapy once patient is stabilized
C Other General Nursing Care
C Treat secondary infections by appropriate Antibiotics
C Treat underlying other pathology. e.g. Anemia, Malnutrition, etc.
C Assessment of consciousness status
C AVPU Scale (A-Alert; V-Voice; P-Pain; U-Unresponsive)
General Management
31
Deteriorating General Condition
Very shallow respiration/severe respiratory distress/feeble heart sounds
Capillary Refill Time > 3 secs
Dusky colour of body/cyanosis
Need of continuous bag and mask (Ambu) ventilation
ABG parameters showing acidosis, hypoxia & hypercarbia
*For District Level Doctors if ventilator is not available they can hand ventilate by Ambu Bag
Indications of Ventilatory Support*
32
Herpes- Acyclovir- 10mg/kg/dose, I/V slowly over a period of one hour, 8 hourly x 21 days.
Varicella Zoster- Acyclovir-10mg/kg/dose 8 hourly, I/V slowly over a period of one hour x 7-10 days.
Malaria- Artesunate- 2.4mg/kg stat, then at 12 hour and 24 hour, then once a day for 7 days
(Change to oral, once patient can tolerate orally). or I/V Quinine- 20mg/kg in 5% Dextrose slowly over a period of 1 hour then 10
mg/kg 8 hourly. Monitor blood sugar and blood pressure.
Meningitis (Pyogenic)- Start with I/V inj. Ampicillin 200-400 mg/kg/day 6 hourly upto 12 gm/day+I/V inj. Ceftriaxone 100-150mg/kg as stat dose then in two divided doses 12 hourly+steroids. Change antibiotics according to culture & sensitivity report and response.
TBM- Anti Tubercular Drugs (INH, PZA, Rifampicin + Ethambutol + Steroids)
Neurocysticercosis- Albendazole oral 15mg/kg (upto 800mg)/day for 7 days. Premedicate with steroid (Prednisolone 2mg/kg or 0.15mg/kg of Dexamethasone) either concurrent with Albendazole or starting Albendazole on the 3rd day of corticosteroid.
In case of suspected Mycoplasma/Rickettsial infection, injection Azithromycin 10 mg / kg slowly IV drip/infusion once daily for 7 to 10 days.
Treatment of Specific Cause if any
Protocol for empirical therapy :
(Till definite diagnosis is established)
1. Ceftriaxone 100-150mg/kg as stat dose then in two divided doses 12 hourly.
2. Artesunate- 2.4mg/kg stat, then at 12 hour and 24 hour.
3. Acyclovir-10mg/kg/dose, I/V slowly over a period of one hour thrice daily.
33
C Myocarditis and heart Failure:
Bed rest
Fluid restriction (70%)
BP monitoring
Furosemide 1-2 mg/kg/IV 8 hrly
Enalapril 0.1mg/kg/day in 2 divided doses
IVIG 400mg/kg/day for 5 days (those who can afford)
Dexamethasone 0.5mg/kg/day for 5 days (those who can not afford IVIG)
for Neurocysticercosis or complications such as
Myocarditis and Heart failure
Dopamine and of Dobutamine may be used at any stage as per requirement
C Renal insufficiency:
Input/output charting
Daily weighing2 IV fluids 10% Dextrose 400ml/m /day
5% Dextrose in N/5 saline (to replace urinary output)
Correction of electrolyte imbalance
C Anemia:
Hb < 5 gm% - Packed cell (RBC) 10 ml/kg
Hb > 5 gm% - Oral Iron (4-6 mg/kg/day) and folic acid supplementation
C Thrombocytopenia:3 Platelets count < 20000/mm or severe bleeding-Platelets transfusion
Treatment of other associated complications
Contd....
34
Contd....
C GI Haemorrhage:
R/T suction of gastric content
Blood transfusion
I.V. fluids
Ranitidine 2-3mg/kg/day
Sucralfate syrup 0.5ml/kg/dose 6 hrly
Injection Vit. K 10mg stat
C Pulmonary oedema:
Furosemide 1mg/kg/IV 8 hrly
Fluid intake
35
C Disability Limitation:
Bed rest
Frequent change of postures-(every 2 hr)
Change bed sheets-Daily
Condom connection and catheterization (to every incontinent/unconscius child)
Control of cerebral oedema
Control of seizures
Control of fluid and electrolyte imbalance
Eyes (fundoscopy for papiloedema, optic neuritis and atrophy)
Pulmonary oedema
GIT Haemorrhage
Secondary bacterial infections
C Feeding:
Unresponsive
Breathing and circulation unstable
Secretions in airways
Responsive
Respiration and circulation stabilized
Coughing, swallowing absent
Conscious (biting, chewing and swallowing)
-R/T Feeding-Oral Feeding}
-Nil orally -R/T suction of gastric contents -I.V. Fluids
}
36
A. Investigations :
Complete Blood Count.
Antigen based RDT or Microslide for Malaria Parasite
Blood glucose
Peripheral blood smear
Serum electrolytes.
CSF and blood for serology- IgM ELISA/virus identification, cells, sugar, protein & JE/Typhus/Mycoplasma status
CSF is preferred since by the time patient presents with CNS manifestations the level of viremia in blood has decreased and there is cross reaction with other flaviviruses.
Other test if necessary - LFT (SGOT, SGPT, serum bilirubin etc)/KFT (Blood urea, Serum creatinine etc) blood culture/x-ray/ultra-sound/CT/MRI/ECHO/ any specific test-enzyme/ECG/EEG/HBsAg/serum protein/prothrombin time/ suspected etiology at appropriate facilities.
Blood test for suspected Leptospirosis
Virus identification is possible only in Apex Referral Laboratories (also at RMRI- Patna, NIV- Pune/Gorakhpur, KGMU- Lucknow) for selected cases if decided by investigating team.
LP to be done if needed at district level.
B. Specimen Collection :
Blood (serum) and CSF specimen are to be collected. Blood specimen should be collected within 4 days after onset of illness for identification of virus and at least 5 days after onset of illness for detection of IgM antibodies. A second convalescent serum sample should be collected 10-14 days after the first sample or at the time of discharge/death if possible/permitted.
Blood/Serum-
Equipment required :
5ml vacutainer tube (non-heparinized) with 23 gauze needle/5ml syringe with needle
Investigations, Sample Collection & Transportation
Contd....
Man
dat
ory
at P
HC
lev
el
37
5 ml blood collection tube if syringe and needle are used for blood collection Disposable gloves and face mask Tourniquet Sterilized swabs Sterile serum storage vial Specimen labels, marker pen Band aid Zip lock plastic bags Lab request form Cold box (vaccine carrier) with ice pack First-aid kit
Collection Procedure :
Collect 5 ml blood in a sterile tube labelled with patient identification and date of collection
Keep at room temperature till clot retracts from serum0 Blood can be stored at 4-8 C for 24 hrs before serum is separated, do not freeze
whole blood
Transport whole clotted blood specimen to laboratory on ice if it can reach lab in 24 hrs/centrifuge at 1000 rpm for 10 mins to separate the serum or if centrifuge is not available carefully remove serum with a pipette and transfer
0serum to a sterile vial and store at 4-8 C for 2 days
C. Transportation :
Specimen Should be transported to laboratory as soon as possible, do not wait for collection of additional specimen.
Put specimen in zip pouch/plastic bag with absorbent material (cotton/tissue).
Use vaccine carrier/thermos flask for transportation. In vaccine carrier use frozen packs along the sides and place specimen in the center. Transport in reverse cold chain.
Place lab request form in a plastic bag and tape to inside of carrier.
Inform the lab about the time and manner of transportation.
Transport the serum in vaccine carriers with four ice packs within 48 hrs or it 0can be stored at 4-8 C for 2 days.
0 If a delay is anticipated sera should be frozen at -20 C and transported on frozen ice packs. Repeated freezing and thawing should be avoided as it affects
the stabilityof IgM.
38
All attempts should be made to collect CSF specimens for confirmation of diagnosis.
Collection :
Lumbar puncture is the most commonly used means of collecting specimen
Patient is positioned on his side with knees curled up to his abdomen,
occasionally it is performed with the patient sitting or bent forward, fluid is
collected (usually 2-3 ml).
Skin is scrubbed and local anesthetic is injected over lower spine. Spinal
needle is inserted usually between L3 and L4 vertebrae.
Once the needle is in sub-arachnoid space pressure can be measured and
fluid is collected in a sterile screw capped bottle.
After sample is collected, the needle is removed and area is cleaned.
Patient is advised to lie flat for 6-8 hrs.
Perform physical examination of CSF, indicate the findings on the laboratory
requisition form and transport to the laboratory as soon as possible. Store at 04 C if delay in processing is anticipated.
Storage and Transportation :0
Store at 4 C as soon as possible after collection and dispatch at the earliest
with four ice packs in vaccine carrier/thermo flask.
For PCR-transport specimen on dry ice.
A designated person should be responsible for storage, packing and
transportation as per guidelines on previous page.
Lumbar Puncture & CSF Examination
Note: Lumbar puncture should be done in the facilities with laboratory service after stabilization of patient because there is chance of herniation
39
C Physiotherapy/PMR
C Advice of pediatric neurologist
C Correction to fix deformity by orthopaedic surgeon
C Child psychologist advice
C Various prosthesis
C Artificial appliances
C Eye and Ear check-up
Rehabilitation
40
Annexure-AReporting of Case
Case Investigation FormTo be filled up by Medical Officer at time of first contact with Health Facility and be to kept with BHT
ACUTE ENCEPHALITIC SYNDROME / JE CASE INVESTIGATION FORM
Registration Number : AES-
Reporting Information
Date of Case Reported
Date of Case Investigated
Patient Information
Patient's Name: Date of Birth:
Father's Name:
Village/Mohallah:
District:
Notified by
Investigated by
Sex:
Age: Years
Religion: Muslim/Hindu/ Other:
Landmark:
Block/Urban Area:
State:
Months
- - -
/ /
/ /
Travel History over Two weeks from Onset of First Symptoms
Date FromDate toAddress
Block
District and State
Immunization History
JE Immunization Yes/No/Partial/Unknown Date of last JE Immunization / /
Signs and Symptoms
Date of onset of first symptoms
Change in mental status Yes/No/ Unknown
Fever Yes/No/ Unknown
Headache Yes/No/UnknownParalysis Yes/No/Unknown
Unconsciousness Yes/No/Unknown
Neck rigidity Yes/No/ Unknown
Sample Collection, tracking and results
Date Collection
Date Sent
Date Result Condition*
Laboratory Result (Circle)
CSF
Serum 1
Serum 2
Positive UnknownNot-tested Negative
Positive UnknownNot-tested Negative
Positive UnknownNot-tested Negative
Diagnosis and final classification
Final Classification
Clinical Diagnosis
Discharge Status
Status of Patient Death/Discharge/Referral/LAMA
If Alive status of recovery Recovered completely/ Recovered with disability
If died, date of death:
Laboratory Confirmed JE / Known AES / Unknown AES
Date
(Name & Signature)Designation
Seizure Yes/No/ Unknown
*Condition is adequate if specimen is transported in reverse cold chain
/ /
/ /
/ /
Mob.No.
Address:
321
41
Annexure-BReporting of Case
Laboratory Request FormTo be filled at time of first contact with Health Facility by Medical Officer
JAPANESE ENCEPHALITIS LABORATORY REQUEST AND REPORT FORM
If sample is bad specifyAdd in the following information:Fever at onset Y N Duration .........Seizures : Y NAltered level of consciousness : Y NNeck rigidity: Y N
(Name and Signature) Designation
*Sample is good if:
There is no leakage
Of adequate quantity
Brought in cold chain
Documentation is complete
Patient Registration Number: Date:Patient name:Age:
Province:Town/village:
DistrictName of health facility:
Number of doses of Japanese Encephalitis vaccine: Date of last dose:
Date of onset of illness
Name & address of treating doctors:
Clinical Feature:
Specimen Type
(1)
(2)
(3)
Specimen ID Date of Collection Date of Shipment
Name of person to whom laboratory results should be sent:
Address:
Telephone/Mob.No.: E-mail:
For use by the receiving laboratory:
Name of laboratory:
Name of Person receiving the specimen:
Specimen condition*
Specimen Type
Date ofReceived in
LabDate Result Test Type Test Result
Date of Result to Program
/SenderRemarks
Name of Parent or guardian:
/ /
Any other informationSource : WHO Draft document operational guidelines
42
1. Essential equipments at the PHC/Referral/Sub Divisional Hospital level:
Glucometer with strip
Air way sizes 0 and 1
Mucus sucker
Rubber feeding tube of various size (10,12,14)
5 ml & 2 ml syringes with needles
Thermometer
Adhesive tape
Enema set
Oxygen
IV cannula, 22 to 24 gauze
Ambu bag
Foley's catheters of various sizes
2. Essential equipments at the Sadar Hospital/Medical College level:
Glucometer with strip
Air way sizes 0 and 1
Mucus Sucker
Rubber feeding tube of various size (10,12,14)
5 ml & 2 ml syringes with needles
Thermometer
Adhesive tape
Enema set
Oxygen
IV cannula, 22 to 24 gauze
Ambu Bag
Foley's catheters of various sizes
Lumbar puncture sets
Provision for cerebrospinal fluid analysis
Essential Equipments at the PHC/Referral/Sub Divisional Hospital/Sadar Hospital/Medical College
Annexure-C
(for Management of AES)
43
C Tablet/Syrup/Injection Paracetamol
C ORS
C Inj. Adrenaline
C Inj. Diazepam
C Inj. Phenytoin
C Inj. Dexamethasone/or Hydrocortisome
C Inj. Mannitol 20%
C Inj. Phenobarbitone
C Inj. Ceftriaxone
C Inj. Artesunate
C Diazepam rectal/Diazapam Suppository.
C IV fluids N/2 saline, Isolyte - P, 10% Dextrose, 3% Hypertonic saline.
C Normal saline
C Ringer Lactate
C Tab/Inj. Frusemide
C Oral Glycerol
C Glucose Powder
C Suspension Valproate
C Vitamins
C Midazolam- Intra Nasal Spray
C Lorazepam
Annexure-D
Essential Drugs at the PHC/Referral/Sub Divisional Hospital
(for Management of AES)
44
C Tablet/Syrup/Injection Paracetamol
C ORS
C Inj. Adrenaline
C Inj. Diazepam
C Inj. Phenytoin
C Inj. Dexamethasone/or Hydrocortisome
C Inj. Mannitol 20%
C Inj. Phenobarbitone
C Inj. Ceftriaxone
C Inj. Artesunate
C Diazepam rectal/Diazapam Suppository.
C IV fluids N/2 saline, Isolyte - P, 10% Dextrose, 3% Hypertonic saline.
C Normal saline
C Ringer Lactate
C Tab/Inj. Frusemide
C Oral Glycerol
C Glucose Powder
C Suspension Valproate
C Vitamins
C Midazolam- Intra Nasal Spray
C Lorazepam
C Inj. Dopamine
C Inj. Acyclovir
C Inj. Paraldehyde
C Inj. Ampicillin
C Syrup Chloral hydrate
C Syrup/Tab Haloperidol
C Inj. Chloramphenicol
C Inj. Azithromycin
C Capsule Doxycycline
C Dobutamine
Annexure-E
Essential Drugs at the Sadar Hospital/Medical College Hospitals
(for Management of AES)
45
Components of Paediatric Intensive Care Unit (PICU) *
Equipment Quantity/ies
1.1 ICU Beds 10
1.2 Bed Side Monitors (with facility to measure and display following parameters);
Heart rate/Respiratory rate/Temp.Non-invasive Blood Pressure (NIBP)Oxygen Saturation (SpO2)
ECG1.3 Central Monitoring Station1.4 Defibrillator 11.5 Central Gas Pipeline (Oxygen, compressed air,
vaccum)(2 pts. for O and 1 for vacuum and 2compressed air)
1
1.6 Paediatric Ventilators 5
1.7 ABG Analyzer 1
1.8 Syringe Pumps 201.9 Misc. Instruments/Equipment1.9.1 Nebulizer 11.9.2 X-ray View Box 11.9.3 Transport Ventilator 11.9.4 Transport Monitors 11.9.5 Over Head Warmers 21.9.6 Recovery Trolley 11.9.7 B type O Cylinder 2 1
1.9.8 Ambu Bag with Mask (Paediatric and adult size) 5 (each size)
1.9.9 Suction Machine 11.9.10 Laryngoscope 5 (of different size)
1.9.11 Endotracheal Tube with cuff and without cuff
12
1
Note: The estimated total cost of equipments has been decided by the Government. The
implementing authorities in the respective states may be requested to adjust the additional
cost of the equipment within the allocated budget. Any additional expenditure on equipment
would have to be managed from state resources only.
Annexure-F
*As per GoI guideline
46
Annexure-G
List of Equipment/Furniture required for PMR Department*1. Wards (Special requirements):
Paraplegia beds-steel plate base with 3 components - 10
Dunlop mattress- 10cm thick - 10
Bedside tables - 10
Trolleys - 02
Water mattresses - 10
Tricycles (2-hand operated, 2 motorized) - 04
Wheel chairs - 10
Adjustable dining/reading tables - 05
Pillows-6 per bed - 60
Quantity
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
One
2. Physiotherapy
Exercise Therapy
Sl No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Physiotherapy Equipment
Electrotherapy
Short wave diathermy
Ultrasound
Muscle stimulator
TENS
Traction-Lumbar & CervicalWax therapy
LASERInterferential therapy
Infra-Red Lamp (IRL)
CPM Apparatus (Continuous Passive Motion)
Shoulder wheelShoulder pulley bracket-wall mounting
Shoulder abduction ladder
Wrist circumductor
Wall barGrip exercise with six springs
Weight cuffs (1/2-3kgs)
Parallel bar
Dumbells ironMedicine ball (1kg, 2kg, 3kg, 5kg)
Quadriceps table
Contd....*As per GoI guideline
47
3. Equipments Required for Occupational Therapy:
4. Specialized requirements:
Gait and urodynamic laboratory
oneoneoneoneoneoneone
Optional
twotwotwotwo
Optionaltwotwotwo
twotwotwo
Sl. No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Occupational therapy equipments
Bed with mattress-double bed with pillows
Mirror (adjustable & per table)
Cogni toys
Finger ladder
U.E. sling
Shoulder wheelSuspension U.E
Supra board
Nuts & bolts boardHand exercise tableStool with casterBolsters big
U.E. cycle
Sanding boards bilateral & reciprocal
Coordination pig board with adjustable height
Post office box
Quantity
Two
One
One set
One
One
One
One
One
One
Two
One
One
One + One
One
One
One
2324252627282930
3132333435363738
394041
Treatment Equipments
Mobility Aids
Stair Case-Corner typeCouch for suspensionMulti exercise therapy unitAnkle and leg exerciseStatic cycleExercise matPostural training mirrorAnkle exerciser
Wheel chairWalker adultWalker pediatricProne crawlerWalking frame
Crutch foreamAluminum stick
Examination couch wooden (Foam padded)Tilt tableActivity mattress
Crutch axillary
48
VERBAL AUTOPSY SAMPLE QUESTIONNAIRE
for
AES/JE (AES Unknown & JE Confirm) DEATH CASE
To be filled up by members of the committee at the time of Verbal Autopsy
(To be used at all government health facilities)
Reporting Information
Date of Case Reported :................................ Notified by :......................................................................................................................................
Date of Case Investigated :............................ Investigated by :...............................................................................................................................
Patient Information
Patient's Name :............................................................................................... Sex :........... Date of Birth :................. Age-Years....... Months........
Father's Name :.................................................................................................................................. Religion- Muslim/Hindu/ Other :....................
Address :......................................................................................................... Village/Mohallah :............................. Landmark :.............................
Block/Urban Area :........................................... District :....................................... State :.......................... Mob.No. :..........................................
Travel History over Two weeks from Onset of First Symptoms
Date from: 1 ...................................................... 2 ...................................................... 3 .....................................................
Date to: 1 ...................................................... 2 ...................................................... 3 .....................................................
Address :......................................................................................................... Village/Mohallah :............................. Landmark :.............................
Block/Urban Area :............................................ District :....................................... State :........................ Mob.No. :...........................................
Immunization History :....................................... JE Immunization- Yes / No / Partial / Unknown Date of last JE Immunization :..............................
Signs and Symptoms
Date of onset of first symptoms :................................. Headache Yes/No/Unknown :..................... Change in mental status- Yes/No/Unknown
Paralysis Yes/No/Unknown :...................................... Fever Yes/No/ Unknown :............................ Unconsciousness- Yes / No / Unknown
Seizure- Yes / No / Unknown Neck rigidity- Yes / No / Unknown Date of death :.............................
C Probable cause of death :
C Were the drugs and equipments as per Standard Operating Procedure Module available in health facility at the time of visit of team? Please elaborate.
C Was the patient treated at the health facility as per Standard Operating Procedure guidelines ?If yes please give details.(Use extra sheet if need be)
C Final opinion of Verbal Autopsy Team:
(Name, Signature & Designation of members of the committee with date)
Note- The audit team will carry a copy of Standard Operating Procedure for reference on spot.
District level committee- Chairperson- Civil Surgeon of concerned district
Committee members- ACMO, DIO and District VBD Control Officer
Medical College level committee- Chairperson- Principal of concerned Medical College
Committee members- HoD of concerned Department & two Senior Medical Officers
Verbal Autopsy Committee Members
Annexure-H
The Verbal Autopsy Format & Standard Operating Procedure are available on Health Deptt. GoB web portal as- www.health.bih.nic.in on its Operational Guidelines section.
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osclkbV% www.statehealthsocietybihar.org
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